Hardin County Fall Survey

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* 1. How old are you?

60-64

65-69

70-74

75-79-

80-84

85 and above

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* 2. Are you:

Male

Female

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* 3. What type of housing do you live in?

House

Apartment or condo

Mobile home

Senior apartment facility

Assisted Living facility

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* 4. What is your race

White

African American

Asian

Hispanic or Latino

other

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* 5. Do you live alone?

Yes

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* 6. Where do you look for health information?

Your Doctor

other healthcare provider (physical therapist, nurse, pharmacist)

Family or Friends

Council on Aging /Senior Community Center

Newspaper/Radio

internet

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* 7. Do you think that falls are a problem for people in your age group?

Yes

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* 8. Which of the following do you feel are the top 3 reasons that people your age fall? (Select only 3)

Taking medications

Muscle weakness or medical condition

stairs

Position changes such as getting up out of a chair or our of the bathtub/shower

Vision problems

foot problems or type of shoe

uneven surfaces

dizziness or balance problems

Poor lighting

pets

rugs or clutter on the floor

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* 9. How many prescription and over-the-counter medications do you take each day?

1-3

4-6

More than 6

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* 10. In a typical week, how often do you leave your home to run errands, appointments, meetings, shopping, church, etc.?

Less than once per week (for example, once per month)

1-2 times per week

3-4 times per week

Almost every day

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* 11. How many days each week do you exercise? (Activity the increases your heart rate)

0 days

1-2 days

3-4 days

5-7 days

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* 12. Where do you exercist?

YMCA

Wellness Center

Senior Center

other

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* 13. Do you use an assistive device such as a cane, walker or wheelchair?

Yes

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* 14. In general, how would you rate your likelihood of falling?

none

low

moderate

high

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* 15. Have you talked to your Doctor about falls?

Yes

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* 16. Have you fallen in the last 6 months?

Yes

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* 17. If you have, where were you when you fell?

at home

away from home

Hardin County Fall Survey

Fall Among Older Adult in Hardin County

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* 1. How old are you?

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* 2. Are you:

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* 3. What type of housing do you live in?

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* 4. What is your race

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* 5. Do you live alone?

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* 6. Where do you look for health information?

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* 7. Do you think that falls are a problem for people in your age group?

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* 8. Which of the following do you feel are the top 3 reasons that people your age fall? (Select only 3)

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* 9. How many prescription and over-the-counter medications do you take each day?

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* 10. In a typical week, how often do you leave your home to run errands, appointments, meetings, shopping, church, etc.?

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* 11. How many days each week do you exercise? (Activity the increases your heart rate)

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* 12. Where do you exercist?

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* 13. Do you use an assistive device such as a cane, walker or wheelchair?

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* 14. In general, how would you rate your likelihood of falling?

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* 15. Have you talked to your Doctor about falls?

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* 16. Have you fallen in the last 6 months?

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* 17. If you have, where were you when you fell?

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* 18. Optional: Please provide any additional comments or suggestions in regards to fall prevention or information in the box.